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American Association for Geriatric Psychiatry

Chapter 28: Individual Psychotherapy

QUESTION

1.

During psychotherapy with elderly outpatients, the psychotherapist often will utilize which one of the following techniques?

A. Choose a fixed number of sessions with a clear termination date

B. Explore a patient's strengths in the context of an idealized transference

C. Interpret and then discourage formation of an idealizing transference

D. Refuse to allow intermittent or open-ended therapy

E. Utilize reminiscence sparingly

Correct answer is B

RATIONALE FOR QUESTION 1

Psychotherapeutic goals range widely with elderly patients, from providing education about normative aspects of aging to exploring past experiences through reminiscence, to focusing on strengths and supporting efforts to maintain self-esteem. Patients frequently develop a transference to their therapist in which aspects of previous or idealized relationships are transferred, sometimes unconsciously, onto the therapist and into the fabric of the therapeutic relationship. Idealized transferences are common when therapy focuses on age-related conflicts such as death and mortality; vulnerability and helplessness; and pain, illness, and coping. Narcissistic individuals often view both themselves and the therapist in an idealized manner. It is important for therapists to use the transference to the benefit of therapeutic goals; this may mean leaving it alone or it may involve attempting to interpret it for discussion. It is not wise, however, to discourage the formation of an idealized transference because it may be the glue that holds the therapeutic relationship together by bolstering a patient's sense of esteem, hope, trust, and regard for the therapist. In addition, clinical evidence suggests that open-ended therapeutic relationships often are necessary for elderly patients, leaving the possibility open for future contact after termination of therapy.

References

1.Lazarus LW, Sadavoy J. Individual psychotherapy. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 993-1022.

2.Mackin RS, Arean PA. Evidence-based psychotherapeutic interventions for geriatric depression. Psychiatr Clin N Am. 2005;28(4):805-820.


QUESTION

2.

Which one of the following approaches may be useful in the initial psychotherapy session with an elderly patient?

A. Exploring the patient's attitude toward death

B. For somatically preoccupied patients, beginning the discussion with medically oriented information gathering

C. Interviewing significant others, such as family members, before seeing the patient

D. Manifesting an 'upbeat' jocular manner to offset a depressive or anxious attitude in the patient

E. Suggesting the patient begins dating one year after the death of a spouse

Correct answer is B


Beginning the initial therapeutic encounter with an older patient, like any patient, requires that the therapist put the patient at ease in order to develop a rapport and a willingness to work together over time. Exploring the patient's attitude toward death, even if he or she is quite old or frail, usually is not a good idea for the early part of the interview before getting to know the patient and developing a rapport. Many patients are very somatically preoccupied in late life; therefore, beginning the discussion with the medical aspects of their health often is a good way to break the ice. After the loss of a spouse, it may be appropriate to suggest dating at some point, but generally not in the first session. Similarly, meeting with family members before meeting with the patient, particularly if the patient is not having cognitive problems, weakens the working alliance with the patient. It is best to begin the interview with the patient and then ask permission to involve other family members as appropriate.

References


2.Lynch TR, Aspnes AK. Individual and group psychotherapy. In: Blazer DG, Steffens DC, Busse EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004: 443-458.


QUESTION

3.

Which one of the following represents suggested modifications of cognitive-behavioral therapy (CBT) for elderly depressed individuals?

A. Encouraging the patient to list his or her lifelong accomplishments

B. Keeping the patient focused on caregivers (e.g., spouse, children) to demonstrate the available support

C. Keeping the patient focused on early-life events

D. Lengthening the treatment to 30 to 40 sessions instead of the usual 15 to 20 sessions

E. Shortening the treatment to 5 to 10 sessions instead of the usual 15 to 20 sessions

Correct answer is D


Lazarus et al. do not recommend lengthening the treatment sessions because patients may not be able to focus for long periods of time or tolerate lengthy sessions. More sessions allows for a slower learning curve to help the patient reap the most benefit from CBT. Encouraging patients to list their lifelong accomplishments is a feature of reminiscence therapy, not CBT. Keeping the patient focused on early life events is more likely to be a psychodynamic or psychoanalytic approach than a cognitive behavioral approach.

References


2.Mackin RS, Arean PA. Evidence-based psychotherapeutic interventions for geriatric depression. Psychiatr Clin N Am. 2005;28(4):805-820.

3.Miller MD, Silberman RI. Using interpersonal psychotherapy with depressed elderly. In: Zarit SH, Knight BG, eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, DC: American Psychological Association; 1999: 83-100.


QUESTION

4.

With respect to brief psychodynamic or time-limited psychotherapy, which one of the following statements is true?

A. It is a good choice for grief reactions

B. Most elderly require insight-oriented therapy

C. Most elderly require supportive rather than insight-oriented therapy

D. No time limit should be set for the duration of the therapy

E. The therapist should not be expected to delve into conscious and unconscious goals such as resistance to treatment or holding negative beliefs about the self

Correct answer is A


Brief psychodynamic psychotherapy is best used for elderly individuals with clearly defined, circumscribed problems that can be expected to resolve in a limited amount of time. Setting a time limit along with specific treatment goals reinforces the patient's confidence in his or her ability to resolve the problem. The therapist plays a key role by understanding a patient's conscious and unconscious goals (such as overcoming resistance to treatment or holding negative beliefs about the self). The therapist also helps to consolidate disparate aspects of self and validate a sense of normalcy and competency. It is important for therapists not to underestimate a patient's abilities and water down therapy because of an ageist bias that most elderly require supportive rather than insight-oriented therapy.

References




QUESTION

5.

Which one of the following statements is true regarding the efficacy of interpersonal psychotherapy (IPT) and the treatment of depression in older adults?

A. Combination therapy with medications and IPT offers no benefit over psychotherapy alone

B. Frailty is a contraindication

C. IPT typically is open-ended in duration

D. Medication has been shown to be more effective than IPT

E. The efficacy of combined treatment with nortriptyline and IPT reached 70% in older adults

Correct answer is E


IPT is a form of therapy that focuses on grief, interpersonal disputes, role transitions, and interpersonal deficits. This therapy has been adapted for older adults, even those who are frail and suffer from multiple medical problems. IPT typically is of short-term duration and can be provided by trained clinicians in many disciplines. The success rate for combined treatment of depression in older adults who received both nortriptyline and IPT was high, with up to 74% achieving remission of symptoms.

References

1.Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249-265.

2.Reynolds CF 3rd, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA. 1999;281(1):39-45.


QUESTION

6.

Regarding defense mechanisms in late life, which one of the following statements is true?

A. Frail elderly are more likely to employ defenses of infirmity and withdrawal

B. Hypochondria is not a symptom in the elderly, whether they are infirm or not

C. Older individuals show more antisocial behaviors and self-destructive actions when compared to young adults

D. Physical preoccupation does not represent a defense against anxiety

E. Reminiscence is not used as a defense mechanism

Correct answer is A


It is believed that the dramatic defenses of youth such as promiscuity, self-injury, and antisocial behavior diminish throughout life. Frail elderly individuals are more likely to employ the defenses of withdrawal, infirmity, and physical preoccupation to deal with intrapsychic conflict and anxiety. Claims of illness or immobility may be ways to avoid therapy. Some older individuals may retreat into a focus on the past, with overuse of reminiscence.

References


2.Yesavage JA, Karasu TB. Psychotherapy with elderly patients. Am J Psychother. 1982;36(1):41-55.


QUESTION

7.

Which one of the following statements includes relevant principles of psychotherapy with cognitively impaired individuals?

A. Cognitive-behavioral therapy (CBT) should not focus on changing target behaviors

B. In the cognitively impaired patient with delusions, aggressive reality orientation may exacerbate anxiety, psychosis, or agitation

C. Psychodynamic issues do not influence symptoms and treatment response

D. Therapy should focus on the denial of the disability by the patient

E. Therapy should not be directed at minimizing excess disability

Correct answer is B


Psychotherapy with cognitively impaired individuals must work within their remaining reflective capacity and must involve family and caregivers in appropriate environmental manipulation. Psychodynamic issues often influence symptoms and treatment response, regardless of the patient's capacity to address them directly. Therapy often is aimed at minimizing excess disability by correcting sensory deficits, reducing isolation and withdrawal, and improving medical status. CBT focuses on changing target behaviors, which may include such concrete tasks as increasing participation in activities of daily living, enhancing communication skills, and improving hygiene. When delusions are present, gentle redirection of the patient's attention may be helpful; however, aggressive reality orientation may exacerbate agitation or the underlying psychosis.

References



3.Teri L, Logsdon RG, Uomoto J, et al. Behavioral treatment of depression in dementia patients: a controlled clinical trial. J Gerontol B Psychol Sci Soc Sci. 1997;52(4):P159-P166.


QUESTION

8.

Which one of the following is the most appropriate goal of psychotherapy when dealing with crisis situations of elderly individuals?

A. Emphasize the availability of support from caregivers, including the therapist or medical personnel to facilitate adaptation to the crisis

B. Intrapsychic adaptation to the effects of the crisis

C. Understanding the unconscious root causes of distress

D. Return to the best attainable level of function

E. Return to previous level of function

Correct answer is D


When psychological defenses are overwhelmed by crisis, the first goal of therapy is to help the patient return to his or her best attainable level of function, rather than attempting structural or intrapsychic change. Specific goals of psychotherapy during the crisis phase may include mourning for losses, redirection of energy and creativity to a realistic level of functioning, control of regression, and reengagement with new sources of gratification.

References


2.Miller MD, Silberman RI. Using interpersonal psychotherapy with depressed elderly. In: Zarit SH, Knight BG, eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, DC: American Psychological Association; 1999: 83-100.


QUESTION

9.

Which one of the following statements about reminiscence therapy with elderly patients is true?

A. It helps patients find meaning or significance in aspects of their life experiences

B. It helps the patient to feel less alone through improving communication skills

C. It is recommended for patients with severe guilt over past life events

D. It is used to uncover unconscious conflicts

E. It teaches patients to resist automatic negative thoughts

Correct answer is A


Reminiscence therapy is the active elicitation of events and experiences in the patient's life that brought him or her meaning and perhaps underlie the patient's self-esteem, which can be strengthened if there is a history of accomplishments or pride over raising children, etc. Patients who feel severely guilty about past events may not be good candidates for reminiscence therapy because the therapy may stir up old conflicts. Psychodynamic or psychoanalytic therapy focuses on uncovering unconscious conflicts and resisting automatic negative thoughts as a feature of cognitive-behavioral therapy. Reminiscence is not a means of improving loneliness or social skills.

References

1.Butler RN. The life review: an interpretation of reminiscence in the aged. Psychiatry. 1963;26:65-76.

2.Haight BK. Long-term effects of a structured life review process. J Gerontol. 1992;47(5):P312-P315.


QUESTION

10.

Which one of the following is vital to interpersonal psychotherapy (IPT)?

A. The goal of therapy is medication compliance

B. The therapist is active and direct

C. The therapist's attitude is always characterized by goal-directedness

D. Therapy is open-ended, not focusing on short-term goals and problem resolution

E. Work should be focused on reminiscence and life review

Correct answer is B


ITP is goal-directed and focuses on components that are believed to contribute to or maintain depression in late life. The therapist is active and encourages focus of interpersonal disputes, grief, role transitions, and interpersonal skills. IPT is time-limited, often 12 to 20 sessions in duration. Reminiscence therapy and life review are more reflective in nature. Psychodynamic psychotherapy is more likely to be open-ended in duration. While medication compliance is important, it is not a distinct component of ITP.

References

1.Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249-265.

2.Hinrichsen GA, Clougherty KF. Interpersonal psychotherapy: origins, structure and applications. In: Hinrichsen GA, Clougherty KF, eds. Interpersonal Psychotherapy for Depressed Older Adults. Washington, DC: American Psychological Association; 2006: 34-49.



QUESTION

11.

Which one of the following statements is true regarding the psychoeducational component of cognitive-behavioral therapy for panic, anxiety, and agoraphobia in older persons?

A. Avoidance behavior and anticipatory anxiety are not addressed

B. Fears of a brain tumor, stroke, heart attack, and fainting are acknowledged as realistic

C. Panic, anxiety, and agoraphobia are defined with corresponding symptoms shown to be physically harmless and possible to control

D. The aim of the psychoeducational component is the early confrontation with what is feared

E. Written materials and homework assignments are of limited value

Correct answer is C


A cognitive-behavioral therapist educates a patient about definitions and implications of disorders through discussion and written materials. Avoidance and anticipatory anxiety are shown to be counterproductive in the context of symptoms that are neither life threatening nor physically disabling. With practice, a patient can gain control. Fears that symptoms are the signs of a brain tumor or will cause a stroke, heart attack, or fainting must be debunked rather than merely acknowledged. Homework assignments and practice between sessions are vital to maintain gains.

References

1.Gallagher-Thompson DE, Thompson LW. Psychotherapy with older adults in theory and practice. In: Bonger B, Beutler L, eds. Comprehensive Textbook of Psychotherapy: Theory and Practice. New York: Oxford University Press; 1995: 357-379.

2.Mohlman J, Gorenstein EE, Kleber M, et al. Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: two pilot investigations. Am J Geriatr Psychiatry. 2003;11(1):24-32.

3.Stanley MA, Hopko DR, Diefenbach GJ, et al. Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings. Am J Geriatr Psychiatry. 2003;11(1):92-96.


QUESTION

12.

Which one of the following statements regarding managing elders with significant character pathology in the nursing home is correct?

A. Demonstrating lifelong patterns of behavior to the patient facilitates the management task

B. Encouraging a sense of control invites more acting out

C. Keeping interventions focused on the 'here and now' encourages immediate behavior changes

D. Obtaining input from family members undermines the authority of the staff

E. Placing limits on problem-solving behavior often worsens confusional states

Correct answer is C


The issue of managing patients with character pathology in the nursing home setting becomes an exaggeration of managing patients with character disorders at any age. Placing limits on them often is a requirement to contain problematic behaviors. This usually helps to improve their view of their situation rather than worsen their confusion. Obtaining help from family members can be very calming, and their knowledge of the patient may help the staff understand those issues that are more inflammatory versus more calming, which the staff will appreciate. Encouraging a sense of control decreases acting out, particularly if there is a reward system for good behavior and good self-control that dovetails with the policies and procedures of the institution. Keeping interventions in the here and now brings immediacy and directly connects the intervention with the problem behavior, which carries the greatest chance for success.

References


2.Spayd CS, Smyer MA. Psychological interventions in nursing homes. In: Zarit SH, Knight BG, eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, DC: American Psychological Association; 1999: 198-212.

3.Streim JE, Katz IR. Clinical psychiatry in the nursing home. In: Blazer DG, Steffens DC, Busse EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004: 473-500.


QUESTION

13.

Using an interpersonal psychotherapy (IPT) approach to help a patient with worsening osteoarthritis to grieve the loss of his or her status as captain of a

senior tennis team requires focus on which one of the following?

A. Abnormal grieving

B. Diminishing the importance to the patient of the lost role to increase self-esteem and to avoid depressive mourning for the lost personal attribute

C. Interpersonal deficit

D. Role conflict or interpersonal dispute

E. Role transition

Correct answer is E


In IPT, there are four main areas of focus: 1) unresolved grief, 2) interpersonal role disputes, 3) interpersonal relationships, and 4) role transitions. Role transition is a broad category that encompasses the perceived loss of ability, stature, position, respect, and self-esteem. Common role transitions can be retirement, moving out of one's home, cessation of driving, or cessation of other ego-sustaining activities such as being the coach of a sports team. Interpersonal role disputes involve differences of opinion with other individuals; interpersonal deficits refers to those patients who have difficulty getting along with others and are isolated socially, usually on a long-term basis.

References

1.Hinrichsen GA, Clougherty KF. Role transitions. In: Hinrichsen GA, Clougherty KF, eds. Interpersonal Psychotherapy for Depressed Older Adults. Washington, DC: American Psychological Association; 2006: 189-201.

2.Weissman, MM, Markowitz, JC, Klerman, GL. Interpersonal psychotherapy. In: Weissman MM, Markowitz JC, Klerman GL, eds. Comprehensive Guide to Interpersonal Psychotherapy. New York: Basic Books; 2000: 10-37.


QUESTION

14.

Which one of the following psychotherapies is based on the concept that unhelpful biased thoughts underlie problematic emotions?

A. Brief dynamic psychotherapy

B. Cognitive-behavioral therapy (CBT)

C. Interpersonal psychotherapy (IPT)

D. Long-term intensive insight therapy

E. Reminiscence therapy

Correct answer is B


Reminiscence therapy focuses on using a patient's memories about his or her life events and accomplishments to help bolster self-esteem. CBT is based on helping the patient come to terms with his or her biased thinking and automatic negative thoughts that underlie his or her emotional state. Brief dynamic psychotherapy is based on psychodynamic principles. IPT is a manual-based therapy focused on here and now events played out in the person's life, with significant relationships other than that with the therapist.

References

1.Butler RN. The life review: an interpretation of reminiscence in the aged. Psychiatry. 1963;26:65-76.



QUESTION

15.

Giving the depressed patient the 'sick role' and obtaining an inventory of every important relationship in the patient's current life is a feature of which one of the following psychotherapies?

A. Brief dynamic psychotherapy

B. Cognitive-behavioral therapy (CBT)

C. Interpersonal psychotherapy (IPT)

D. Reminiscence therapy

E. Re-training therapy

Correct answer is C


Giving the patient the 'sick role' and taking an interpersonal inventory of every important relationship in the person's life are two cornerstone features of IPT.

References

1.Klerman GL, Weissman MW, Rounsaville BJ, et al. Overview of IPT. In: Klerman GL, Weissman MW, Rounsaville BJ, et al., eds. Interpersonal Psychotherapy of Depression: A Brief, Focused, Specific Strategy. Lanham, MD: Rowman & Littlefield Publishers; 1984: 3-22.



QUESTION

16.

Several types of psychotherapy have been utilized, more or less effectively, with elderly patients. Match each type of psychotherapy listed below with its major goal.

a. Attempts to change thoughts and subsequent behaviors away from the negative and towards a more functional state

b. Augments current coping strategies to increase ability to function under stress

c. By realizing that emotional responses develop in relation to a social context, strategies to change one's responses can be learned

d. Considers past experiences in order to provide current interpretation and boost self-esteem

e. Examines past relationships, how a sense of self has developed, and how this affects current experience

1. Cognitive-behavioral therapy (CBT)

2. Interpersonal psychotherapy (IPT)

3. Problem-solving therapy

4. Psychodynamic psychotherapy

5. Reminiscence therapy

A. a-1, b-4, c-2, d-3, e-5

B. a-3, b-5, c-1, d-2, e-4

C. a-4, b-2, c-5, d-3, e-1

D. a-1, b-3, c-2, d-4, e-5

E. a-5, b-3, c-1, d-4, e-2

Correct answer is D


CBT deals with a person's inner thoughts and the behaviors that result from these thoughts. The therapist works with the patient to change his or her thoughts, leading to more positive and healthy behavioral responses. Problem-solving therapy first considers a pa tient's current coping strategies and then the therapist provides training in new skills and strategies to improve the patient's ability to cope. IPT stresses that emotional responses oc cur within a social context and the patient is encouraged to examine his or her responses to grief, interpersonal conflicts, role transitions, and interpersonal deficits. The goal of psychodynamic psychotherapy is to use the therapeutic relationship to gain insight into past relationships and then to use this knowledge as a tool for change in current experience. Finally, reminiscence therapy or life review is designed to encourage a patient to acknowledge past experiences, both good and bad, and to incorporate these into a current view of his or her self.

References

1.Arean PA, Perri MG, Nezu AM, et al. Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psychol. 1993;61(3):1003-1010.

2.Fry PS. Structured and unstructured reminiscence therapy training and depression among the elderly. Clin Gerontol. 1983;1:15-37.

3.Gallagher-Thompson D, Steffen AM. Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers. J Consult Clin Psychol. 1994;62(3):543-549.

4.Hegel MT, Barrett JE, Cornell JE, et al. Predictors of response to problem solving treatment of depression in primary care. Behav Ther. 2002;33:511-527.

5.Hinrichsen GA, Clougherty KF. Issues in implementation of IPT with older adults. In: Hinrichsen GA, Clougherty KF, eds. Interpersonal Psychotherapy for Depressed Older Adults. Washington, DC: American Psychological Association; 2006: 227-238.




QUESTION

17.

An otherwise healthy 86-year-old woman, grieving over the death of her husband, is referred to you. After gathering a preliminary history and considering antidepressant medication, how would you proceed if you felt interpersonal psychotherapy (ITP) would be helpful?

A. Analyze her inner thoughts

B. Discuss all of her closest relationships including that with her deceased husband

C. Go over all of the good memories of her husband

D. Measure her interpersonal deficits

E. Talk about the changes in her roles

Correct answer is B


While reviewing good memories may be part of a grief response, this is likely to be done in reminiscence therapy. Considering inner thoughts is one of the hallmarks of cognitive-behavioral therapy. Although discussing role changes and measuring interpersonal deficits are part of ITP, you must begin with an in-depth consideration of close interpersonal relationships.

References

1.Hinrichsen GA, Clougherty KF. Grief. In: Hinrichsen GA, Clougherty KF, eds. Interpersonal Psychotherapy for Depressed Older Adults. Washington, DC: American Psychological Association; 2006: 78-91.

2.Klerman GL, Weissman MW, Rounsaville BJ, et al. Goals and tasks of IPT. In: Klerman GL, Weissman MW, Rounsaville BJ, et al., eds. Interpersonal Psychotherapy of Depression: A Brief, Focused, Specific Strategy. Lanham, MD: Rowman & Littlefield Publishers; 1984: 74-95.


QUESTION

18.

Which one of the following statements best describes the results of several studies examining the effectiveness of using interpersonal psychotherapy (IPT) and medication to treat major depression in the elderly?

A. Initial recurrence rates were lowest for IPT plus nortriptyline, but after two years medications were shown to be as good as or slightly better than therapy plus medication

B. Initial recurrence rates were lowest for IPT plus medication and this also proved true at the two-year follow-up

C. Initial recurrence rates were lowest for IPT alone and IPT alone proved the most effective at the two-year follow-up

D. Initial recurrence rates were lowest for medication alone and medication with case management was shown to be most effective to reduce recurrence of depression at the two-year follow-up

E. Initial recurrence rates were lowest for medication alone, but after two-year follow-up psychotherapy alone proved more effective

Correct answer is A


In their initial study, Reynolds et al. reported that their patients who received both nortriptyline and ITP had recurrence rates of 20%; those with nortriptyline alone had recurrence rates of 43%; those with IPT and placebo had recurrence rates of 65%; and those with placebo had a recurrence rate of 90%. Following two years of either maintenance IPT, maintenance paroxetine, maintenance IPT plus medication, or placebo, the recurrence rates changed. The recurrence rates for paroxetine plus IPT and paroxetine only were relatively equal (35% and 37%, respectively). The recurrence rate for placebo was 58%, while the recurrence rate for IPT plus placebo was 68%. Both studies show the effectiveness of medication plus psychotherapy, but the second study indicates the importance of continued medication treatment over time.

References

1.Reynolds CF, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med. 2006;354(11):1130-1138.

2.Reynolds CF 3rd, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA. 1999; 281(1):39-45.

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